01-abouleish-mythbusters crash handout · focus on delays rather than turnover! instead of focusing...

Amr Abouleish, MD, MBADepartment of Anesthesiology

The University of Texas Medical BranchGalveston, Texas

[email protected]

Disclosure

ECG Consultants Technical Advisor

Focus on Staffing Models

Myths in Economics of AnesthesiaConfirmed, Plausible, or Busted? Focusing on turnover time will improve OR

throughput. Because anesthesia revenue includes

time, anesthesia providers prefer longer surgeries.

Going from physician-only staffing to medical direction staffing will reduce staffing costs.

Using “per provider” (aka FTE) measurements allow for accurate benchmarking of productivity.

Focusing on turnover time will improve OR throughput. OR throughput end measure is doing

more cases.

Most commonly: If turnover time was only shorter …

“If turnover time was just shorter, we would be able to do more cases.” A dead horse – stop beating it

The Reality: Turnover time is non-billable time – no revenue for anesthesiologist

Incentive exists to work faster – go home earlier & with same revenue

Anesth Analg 1999;88:72 Anesth Analg 2003; 97:1119Anesth Analg 2011; 112:440

Do One More Case Simply reducing turnover time will not result in

one more case being done.1 Example:

Average turnover is 38 minutes Average h/case is 2.1 hrs Therefore perform 3 cases/OR

= 2 turnovers Reduce turnover by 20% =

8 minutes Per day Per OR = 16 minutes

For short cases (e.g., BMT), turnover time already short (e.g., 10 min)

Anesth Analg 1999;88:72Anesth Analg 2003;97:1119

Abouleish, Amr, MD, MBA Myth Busters: Economic Issues in Anesthesia

Focus on Delays rather than Turnover!

Instead of focusing on reducing turnover, focus on delays

Delays = any turnover greater than maximum acceptable for an OR Example 40 minutes is maximum

Focus on Delays Any turnover <40 minutes, don’t spend time on If delay occurs (turnover of 75 minutes), focus on why

and reduce to 40 minutes Results in 35 minutes saved in the one OR for

that day Compare with the 16 minutes by reducing turnover by

20%

Improving OR Throughput Traditional Approach “Work more efficiently with the people

you already have”

Interdiscliplinary work flow assessment and redesign Involve all services – nursing, surgical, and

anesthesia. Includes physicians

Look at workflow, delays, and system issues

Agree on times and publish different times

Example…

Anesth Analg 1998; 86:896Archives of Surgery 2006; 141:65

Anesthesia Resident’s Life

By involving equipment technician and Pharmacy, reduced the workflow of the anesthesia resident

Did this for all job descriptions

Archives of Surgery 2006; 141:65

So why is not sustainable? Another example: Turnover time and OR throughput

initiative Publish turnover times New rule “Anyone can bring patient back once room is

mopped” Worked great for 3 months …

Educated once, saw success and stopped focusing Other reasons it, approaches may not be

sustainable: Focused on the wrong process, e.g., first-case starts Did not involve all parties

Did not have buy-in from all Alternative approach…

Move from Series to Parallel Processes

Anesthesiology August 2005 IssueSeries to Parallel Process

Not a reduction in actual time, but movement of time to done simultaneously by more people.

Hanss, Anesthesiology 2005;103:391

Increase staff needs.


Series to Parallel Process Not new. Done in past when surgeon had

two rooms! (even two patients in same room!)1

Worked well for surgeon who was fast and doing short cases.

Logical if non-surgical time = surgical time(or significant fraction)

That is if emergence + cleanup + induction is close to surgical time

Used regularly when institution has “preoperative block room” induction rooms for regional anesthesia cases.

1 "This Is No Humbug" Reminiscences of the Department of Anesthesia at the Massachusetts General Hospital, R.Kitz (ed.), 2003

Anesthesiology – July 2008

Regional Anesthesia (Spinal)

15 min patient out of room time

Required More personnel

Facility (especially for setup of back table)

Patient Selection

Anesthesiology 2008;109:25

Increase Staffing Economic sense? Yes, if … Revenue increase more than staffing costs

Dependent on payer mix (revenue) and the staffing costs of the market

Both anesthesia and nursing market Can actually result in reduction of staffing

costs even if more staff needed Reduction of overutilized time (overtime) and

evening staffing (shift differential) Who should use it?

Anesthesiology 2008;109:25

Parallel Process: Should you use?

May make sense in selective cases1

Short cases: Worked well for short cases Similar to historical use

Regional anesthesia2

Block room! (*Time Out issues) Handoff can be done in OR rather than

anesthesia transport (abstract)

1 Anesthesiology 2008;109:252 Can J Anesth 2011; 58:725

Putting “it” in practice

From Mayo Clinic J Am Coll Surg 2011;213:83-94

Multidisplinary group Traditional method

But used new methodology and advantage of integrated system to meet challenges

Key findings and interventions:

Key Findings and Interventions1. Unplanned surgical volume variation Better scheduling (standardized posting), better

predication, better communication2. Streamline preoperative process Both preoperative evaluation and on day of surgery.

3. Reducing non-operative time Parallel processing including procedure and induction

rooms4. Reducing redundant information collection Truly integrated their multiple information systems and

applications5. Employee engagement Communication, end-user focused, multi-disciplinary

involvement

Table 1: J Am Coll Surg 2011;213:86


Mythbuster: Focusing on turnover time will improve OR throughput. Busted if focusing on “turnover time”

alone

Plausible if focused on processes that occur during turnover time.

Confirmed if focus is on process of total perioperative period

Hence, Plausible.






Plausible

“Yes, we bill and get paid for time.”

Yes, we do bill for time tASA billed = base units + time units

tASA = total ASA units

No, this is not an incentive to work slow

Incentive to work faster do more cases and hence more base units

Taxi Drivers …

1 Anesth Analg 2001;93:15372 Anesthesiology 2002;97:608

We bill like Taxi Drivers!

If taxi drivers drives 8 miles with passengers, does he want one long trip of 8 miles, or a bunch of short trips?

If anesthesiologist works 8 billed hours, does he/she want one long case of 8 hrs or a bunch of short cases?

Relationship of Surgical Duration and Billing Productivity

Base Units

Modifiers Time UnitsHospital Pays?

Surgical Duration and Anesthesia Billing

If two groups work 8 billed hours, then for both groups:

Total Base + Total Time Units Total Time Units 4

=tASAhr

= Total ASA Units Hour of Care

tASAhr

Total Base + 32 units 8 hrs

=

Only difference is Total Base Units billed

What determines Total Base Units billednumber of cases done in 8 hrs and base/case


tASA/h and h/case• Less than 1 h/case, base/case important• Small difference in h/case big differences in tASA/h

As h/case increase, tASA/h approaches 4 units/h

Between 1-3 h/case, tASA/h is dependent on both, but more on h/case

Anesth Analg 2003; 97:833


Mythbuster: Because anesthesia revenue includes time, anesthesia providers prefer longer surgeries.

You can bill more if you do more cases in the same amount of time.1,2

i.e., if you are going to be there for 10 hours, you bill more if you do more cases.

Incentive to “work faster”

Anesthesia billing and surgical duration tASA/hr

Myth: Busted!







Plausible

Busted


How to evaluate?

What kind of cost analysis? Cost Minimization

Cost Benefit/ Cost Effective

You do it every day!

What Car Do You Drive? Why?

Chevrolet Aveo$11,245

Lincoln Navigator$56,540

Cost Minimization VS. Cost-Benefit/Effective• Same endpoint• Minimize costs• Easy to understand and perform• Problem: Downstream effect• PERSPECTIVE IMPORTANT

• Different endpoint• Results must be valued• Difficult to understand• Problem: How to value results• PERSPECTIVE IMPORTANT

Cost Minimization vs. Cost Benefit

First always do Cost Minimization analysis. It may turn out that the process with “better benefits” may cost the least. If not then…

Cost Benefit: End-points not the same In this issue, Cost Benefit analysis would include

Physician vs. Advance Nurse Perioperative care vs. OR care ASA physical status 3 or higher patients Outcomes data Unfortunately, not enough time in this presentation

Cost Minimization: First step

Staffing Costs = Compensation

Yearly median compensation1

Anesthesiologists○ Private Practice1 $412,000

○ Academic (all ranks)2 $300,000

CRNA1

○ All practices $186,000

But NOT THE SAME HOURS WORKED

Need to calculate hourly costs

1 2011 MGMA Cost Survey of Anesthesia Practices2 2011 SAAA Compensation Survey


Calculate Hourly Salary

Physician CRNA

Average yearly salary for …55 hours a week

15 hours “afterhours” at “time and half”

For hourly wage: yearly salary divided by 40 hours + 1.5*15 hours

=62.5 “regular” hours

*44 weeks = 2750 regular hours per year

Average yearly salary for … 40 hours a week

All regular hours

For hourly wage: yearly salary divided by 40 “regular hours”

*44 weeks = 1760 regular hours per year

• Assume 2 weeks holiday, 4 weeks vacation, 2 weeks meeting = 52 weeks – 8 weeks = 44 weeks/yr


Based on working “regular hour”

Physician 2750 hrs

CRNA 1760 hrsYrly

CompHrlyCost

MD$412,000

$300,000

CRNA $186,000



Physician 2750 hrs

CRNA 1760 hrsYrly

CompHrlyCost

MD$412,000 $150$300,000 $110

CRNA $186,000 $106



Physician 2750 hrs

CRNA 1760 hrs

Note: Median Instructor and Asst Professor compensation is $293,000 (=$106/hr)

If an academic department needs to cover an additional site, it costs less to cover as MD only.

YrlyComp

HrlyCost

MD$412,000 $150$300,000 $110

CRNA $186,000 $106

Use Hourly Costs and Apply to Staffing Model Examples: From MD only to Medical Direction Many cost issues: Moving to medical direction

model means less physicians to take call Either increase physician compensation to reflect

more call or pay CRNA to work during the “after hours”

Less physician available to provide perioperativemedicine, including hospital committee, preoperative consults, postoperative pain, critical care (if provided)

Examples discussed for illustration ONLY Only looked at covering anesthetizing sites Normalize costs to physician-only practice No mixed model: some physician-only sites and some

medical direction: BUT may be least costly

ASA Newsletter, December 2010, pp.30-34

Examples



Example 1: No salary adjustment for hours worked. Private Practice

MD $411K, CRNA $186K


Example 2: Salary adjusted to reflect working 55 hrs (after hours, weekends). Private Practice

MD $411K, CRNA $296 (40 hrs + 15 hrs at 1.5x)


Example 3: ASC (40 hrs/wk for all). MD salary reduced by 15%. Private Practice

MD $350K, CRNA $186K







Plausible

Busted

Busted

Two Surveys for Benchmarking Anesthesiology Clinical Productivity

Academic Groups: SAAC SurveyAnesth Analg 96: 802-812; 2003Abouleish AE, Prough DS, Barker SJ, Whitten CW, Uchida T, Apfelbaum JL. Organizational Factors Affect Comparisons of Clinical Productivity of Academic Anesthesiology Departments.

A1031 2014 Abstract ASA Annual Meeting2013 Median Values by Facility Type and Size

Private-practice Groups: MGMA Survey2011 MGMA Cost Survey of Anesthesia Practices

2013 Survey released, but limited participationFocused on group level


“Using benchmarks (cases per FTE), you don’t work that hard.”

Consultant uses “outside” benchmarks to determine staffing needs or the actual amount of work being done.

The Hospital Administrator’s or Dean’s Logic


For Anesthesiology GroupsStaffing Needs and Workload For the next day, what determines how

many anesthesiologists you need?1

Number of clinical sites Concurrency Ratio 2nd Shift? – Hours of operations Call and PostCall

What is not relevant? Number of cases in each room Amount of charges Productivity measurements

1 ASA Newsletter August 20012 ASA Newsletter January 2013

Fallacy of the “Field of Dreams” Business Plan …

Fallacy of the “Field of Dreams” Business Plan If you will build, they WON’T come! Groups to have to cover more

anesthetizing locations – within existing facilities and new facilities

But there has not been an equivalent increase in cases or workload

Results in 10-20% decrease in productivity Supporting Evidence

Original article: 2004 and 2006 data Now, compare 2004 with 2010, still consistent Cost Survey of Anesthesia Practices, MGMA

ASA Newsletter, December 20072011 Cost Survey

Median, All Groups

0

200

400

600

800

1000

1200

1400

Encounters per AnesthetizingLocation

Anesthetizing Locations

2004 (n=79)

2006 (n=86)

2008 (n=93)

2010 (n=91)24

28

20

16

12

8

4

Median, All Groups

0

2000

4000

6000

8000

10000

12000

Total Physician Units per OR Total Physician Time Units per OR

2004 (n=58)

2006 (n=51)

2008 (n=65)

2010 (n=52)

“Per FTE” vs. “Per OR”Physician Only >1 CRNA/MD

Cases Per FTE 907 1,653

Per OR 933 915

tASAPer FTE 8,769 16,647

Per OR 9,157 9,323

Hours per Day

Per FTE 4.7 8.8

Per OR 5.1 5.1

tASA = total ASA units

Hours per day = (time units/4) / 250 days*billed time only

* physician only, FTE ≠ OR

2011 MGMA Cost Survey of Anesthesia Practices






Plausible

Busted

Busted

Busted


01-abouleish-mythbusters crash handout · focus on delays rather than turnover! instead of focusing...

Documents